“I seem, then, in just this little thing to be wiser than this man at any rate, that what I do not know I do not think I know either..”
Socrates

Apology by Plato

The events of the last week will undoubtedly shape the future of Britain in a monumental fashion. First, an election like none we have seen for fifty years. Called in hubris, led to nemesis, won, in truth, by no one. History-making nonetheless. The prevailing wind of politics has changed, now blowing Left of centre for the first time in nearly a decade. Corbyn has an approval rating of +6, Theresa May a disapproval rating of -34, nearly mirror opposites of where they stood in November. Who knew?

Theresa May and the Conservatives struck a conciliatory tone. “Austerity is over” they said, in radio interviews, in leaked excerpts from backbencher committee meetings. The “mood has changed” they said.

As details drip out of what will undoubtedly be known as the biggest domestic disaster since Hillsborough, a hazy but consistent picture coalesces. The fire began reportedly in a fourth floor flat, starting with a fridge. The residents had campaigned for years before about power surges in the building, about the risk of a lethal fire with appliances, but sadly, were ignored. Within minutes, it is reported, the fire had spread out of a window and roared up the side of the tower, consuming the external cladding system as one resident described “like matchsticks”. This external cladding had been part of a recent £8.7 million refurbishment, subcontracted by the private enterprise managing the tower, KCTMO, to update the insulation and aesthetic aspects of the outer structure. In the Times today, it is reported that the cladding material used is illegal in structures greater than 18 metres, is flammable when an alternative fire resistant material would’ve cost just £5000 more, and is illegal in Germany and the USA. Sky News’ Faisal Islam shared a BRE presentation this weekend, a diagram of exactly the kind of disaster that befell Grenfell, dated June 2014, three years ago exactly. In summary, we await the public inquiry that must happen, but it seems 58 (at time of writing) people died in a preventable disaster, that was forewarned, already forestalled in other countries, and seems to have been the result of thoughtless (one hopes) cost cutting from a private company.
But, as Damian Green stated in an extraordinary Radio 4 interview, “we must await the experts”.

Which struck a chord with me.

The mantra “prevention is better than cure” is as true in medicine as it is in fire fighting. Much of what we do, day to day, is about preventing future disease, rather than treating it’s corollaries. We use safety cannulas for preventing needlestick injury, we campaign to stop smoking to prevent lung and other cancers, we screen and treat alcoholics on admission to hospital to prevent deadly withdrawal seizures. When we see impending disaster threatening human life, we have a duty to act, as best we can.

A disaster likely already happened in the NHS, and I cannot help but see the parallels with Grenfell. In February of this year a Royal Society of Medicine Report looked into what was explained away by the government as a “statistical blip.”. Since 2010 the death rate in the U.K. was rising, for the first time in fifty years. More people were dying. To be exact, 30,000 “extra” people died in 2015 compared to what was expected. This study attempted to explain where these extra deaths came from. Was it a subpar flu vaccine one season , as Jeremy Hunt, once and current Health secretary, had claimed? No, the study concluded, the only explanation that fit the data was that 30,000 excess deaths were most likely a direct result of cuts to health and social care services.

Let that sink in.

30,000 men and women, potentially your grandmother or father, sister or uncle, whose deaths were in some way contributed to by cuts to services in the name of “austerity”. Like Grenfell, cutting corners and saving pennies, led to a national disaster. Like Grenfell, multiple agencies have limited oversight over the system as a whole. Yes, the buck stops with the government, but I’m sure they can pass it through any number of government and non-government subsidiaries. Like Grenfell, this essential public service, is sub-contracted in places to private companies, beholden to shareholders as much, if not more, than to the public they are supposed to serve. And like Grenfell, warnings about impending disaster, from “experts” and public alike, have fallen on deaf ears. But unlike Grenfell no one saw these deaths for what they were, a national disaster on a behemoth scale.

If you think I’m politicising this tragedy, you have it backwards. The politics came first, then the tragedy.

Which brings me back to where we started. “Austerity is over” they said. The “mood has changed” they said. As if austerity were always a fanciful choice, a frivolity that was chosen on a whim, as one might decide on a suitable tie, or a wallpaper for the living room. I don’t remember anyone claiming austerity was a “mood” when Osbourne and Cameron were laying waste to health and social care budgets, schools and police funding. Austerity was essential, they said. We have to “live within our means” they said. Except some of us didn’t manage to. Potentially as many as 30,000 of us, our most vulnerable.

So now austerity is over. Was it ever actually necessary? The short answer is no. The long answer is, perhaps for a while, but ultimately still no. Despite what the Mail and Sun has peddled for half a decade, the idea the economy is akin to a household budget is laughable. Pretending we only have control of spending in a government trying to “balance the books” is patently stupid; a government sets it’s own revenues, through tax and VAT, NI and council tax, levies and custom duties, subsidies from other countries, like the EU. Austerity was harmful to our economic recovery. This isn’t left wing socialist claptrap, this is mainstream economics. The IMF agrees as did a large backing of the UK’s top economists. This is economic theory that goes back a hundred years. Any economist could’ve told you that. But of course, we had had enough of listening to “experts” then.

Apparently that’s all changed now.

If we are listening to architects and fire officers again, perhaps we could list to economists and health experts again too, to teachers and police federations. To paraphrase Socrates, wisdom is knowing what one does not know. As a doctor I’ve begun to understand this more and more. Being conscious of the limits of my knowledge makes me safer, means I can operate with uncertainty and know where I need a colleague’s advice, or my boss.

In the age of the internet it seems we now know everything, but understand nothing. For too long we all “knew” that austerity was necessary, that “too much red tape” was throttling business and enterprise, that the NHS was “bloated” and spending “too much money”. Did any of us examine where this “knowledge” came from?

Now we see we knew nothing at all. I hope from these tragedies we can salvage some wisdom.

In an impassioned interview, the MP David Lammy spoke about the “safety net” of schools and hospitals, of decent housing, that is falling apart all around us. Austerity has shredded that safety net, and many have died slipping through the gaps.

Austerity is over, they say. I think we can rebuild this safety net, I hope we can fix the NHS.

You hear this phrase a lot; being a doctor is “just a job”, but funnily enough in widely different contexts. On the one hand, the “higher calling” of medicine is derided by some, who insist it’s “just a job” like any other. On the other, doctors under extreme pressure need to know sometimes that their work is “a job”, it should stay compartmentalised and allow them a life outside the hospital or surgery, to balance their own mental health against their working lives.

Which is it?
I don’t think anyone who has working in any emergency setting with human beings would accept the derogatory label of “just a job”, whether that job is doctor, nurse, physiotherapist, pharmacist, fireman, policeman, or paramedic. The normal course of a human life is long periods of normality and stability, punctuated by “Life” with a capital L; births, deaths, marriages, divorces, comedy and tragedy. There’s only so much of that a human mind can take, few of us can stand constant turmoil and upheaval. That’s why the mental health of those in extreme situations suffers: refugees, long-term domestic abuse, and homelessness amongst others.

Being in an emergency job such as medicine means you are party to a constant stream of Life events: births, deaths, monumental illnesses. All the things that intrude into our bubble of stability to rudely remind us of what we already know but wilfully forget: life is random, and hard, and cruel, and important, and wonderful.

So medicine isn’t “just a job” in that sense: it’s an enormous privilege to bear witness and to help human beings through the hardest and most real times in their lives.

But if you let that tragedy in too much, you expose too much of yourself to that constant stream of suffering, you run the risk of your own mental health, exceeding your mind’s capacity to process capital L Life events.

That’s why it’s important to know in a positive sense that medicine is “just a job” too.

Knowing it’s “just a job” means you know you can walk away, which validates and empowers that unconscious choice to walk back in again.

We all chose to do something important with our lives, but we should all recognise that that was a “choice”, and take heart in that.

We should always recognise that we chose to help others, and that no one has an infinite individual capacity to do so; that’s why we work in teams, that’s why we do go home, that’s why we should remember to look after ourselves so we can look after others properly.

So yes, medicine is “just a job”; you have the freedom to walk away at any time, and, I hope, be empowered to choose to come back again. It’s a job, yes, but it’s a job like few others; it’s an enormous privilege and it is honestly one of the best jobs in the world.juniordoctorblog.com

“The airline industry has learnt that pilots must feel they can speak out”

Jeremy Hunt, May 2016

Imagine this.

You are a doctor, resident in hospital, not quite a consultant. You are employed by the hospital, but you rotate through different areas and different hospitals to broaden your experience of different practices. This is designed to make you a better, safer doctor.
One day you come to work, and find you are the only doctor working- there is no one else rota’d to be there. You have to look after your own hundred patients, but now you need to look after two hundred more. You are desperately worried this is not safe. People might get hurt.
As you have been taught to do, as a doctor and a hospital worker, you raise the alarm. You phone your bosses and tell them, you phone their bosses and tell them too. You try your best to keep people alive.
A few months later you sit down with your bosses, and they feel you harmed the reputation of the hospital. They sack you. Not just from that job, but from all training. In a single swipe, your career is over.

Fair? No. Safe? Definitely not. Legal? Surprisingly, and reprehensibily, yes.
At least according to a similar recent legal case against a junior doctor, Dr Chris Day, that decided that the sacking of a doctor for raising alarms over patient safety, for refusing to cover up negligence and potential harm to patients, is not only legal, but a ‘conscious choice of parliament’. The case is currently going to appeal in the Court of Appeal.
Does that sound right to you? As a patient? As a taxpayer? Your health service, at the absolute frontline, is staffed by junior doctors. These are the doctors that see you when you walk in the door, they will see you every day in hospital, they will do your surgery or keep your lungs breathing for you, they will resuscitate you if your heart stops beating. If there’s something wrong, you can guarantee, a nurse or a junior doctor will see it.
Legally- the hospital can’t sack a doctor for speaking up there and then. But doctors in training rotate department every 4-6 months and rotate hospital nearly every year. There is nothing to stop a ‘troublemaking’ doctor who points out dangerous care from having their career ended as soon as they move on to their next placement. A legal loophole, so dangerous it could swallow the entire NHS.
This has huge implications. Now we know this, many doctors, myself included, would think twice about speaking out. That in itself is a crime. We have mortgages and families- our livelihood cannot rely on the goodwill of pressured hospital managers. If a manager decides to, they can end your career, without recrimination.
I’d like to say the BMA and the GMC would step in to protect a doctor in this situation. The BMA proposed a clause in the new contract to cover this, but it’s legally flawed. The GMC have just been taken over by the department of Health, a conflict of interest in the making.

I’d like to say the Health Secretary, with his long term obsession with ‘whistleblowing’ and patient safety would help- but he himself spent taxpayer money cementing this loophole, keeping junior doctors vulnerable to dismissal for raising alarms.

How has this happened?

Well, all roads lead back to the government appointed body called Health Education England. Trainee doctors are employed by hospitals but hold a general training ‘number’ with HEE that delivers the doctors training over years, and partly pays their salary to their rotating hospital. This arrangement means they aren’t technically covered in law as our ’employer’, so can act with impunity in dismissing whistleblowers.

Funnily enough this is the same ‘training’ body that is threatening hospitals to cut funding for junior doctors if they don’t impose the contract upon them. This is how Jeremy Hunt dodged the legal challenge against imposition- by passing the buck, once again, to an organisation that can’t be sued, currently outside employment law. Proving they are legally our employers, as Chris Day is arguing, may have huge implications for further challenging the ‘imposition’ of the junior doctor contract.

Throughout this year we, as trainees, have fundamentally lost trust in the system. Through incidents like this, through the junior doctor contract dispute, through the years of increasing pressure on resources, target chasing and being ignored.
We have lost trust in the structures that run the NHS and their heads- Health Education England has proved it is neither interested in the ‘education’ of its members nor the ‘health’ of the patients they protect.
As long as we don’t get sacked, we won’t be ‘junior’ doctors for long. In time we will all be your consultants and GPs, the clinical leaders of the NHS. What then? Will we still carry a culture of fear and denial, instilled in us by a system that’s supposed to train and nurture us? Let’s hope not.

The future of a safe NHS depends on it. If you want to do something to safeguard that future, donate to Dr Chris Day’s legal fund here. He needs to raise £100,000 to continue his fight for whistleblowers everywhere.

Yesterday in the Mail Hunt made at least two completely bogus claims;
1. He ‘won’ the judicial review into imposition and gained High Court backing for the junior contract

2. Post Brexit he is going to remove foreign doctors and replace them with ‘homegrown’ trainees

There’s been enough of heated opinion lately- so let’s just serve cold hard facts.
1. The Justice 4 Health team took Hunt to court on three premises- that a) he does not have power to impose the contract b) that he acted without clarity and transparency and c) he acted irrationally. Despite a lot of press spin saying Hunt won, he actually just dodged the issue, by claiming that he never imposed and ‘no junior doctor’ thought that he was. As in last week’s blog here is the many instances that Hunt said he was.

The case pushed Hunt to clarify in law that he isn’t imposing the contract, simply passing the buck to local hospitals. The judge also found he could’ve acted with less ambiguity but found it hard to demonstrate the high legal threshold for irrationality.

So far from ‘winning the case’, Hunt was forced back from claiming falsely he was imposing leaving local negotiations with hospitals now a real possibility.

Secondly, Hunt’s plan to replace foreign doctors with ‘homegrown’ talent is as laughable as it is xenophobic.
We are already in the midst of a workforce crisis- applications to medical school dropped 13.5% in the last 5 years, and increasing numbers of junior doctors are leaving training and the country. On top of this, the existing doctor workforce increasingly cover the work of two or more doctors- 7 in 10 doctors work in departments where at least one doctor is missing, 2/5 of consultant posts are unfilled, and 96% of doctors work in wards with nurse shortages.
To add insult to injury, health education England, the body that funds training of so-called ‘homegrown’ talent, has had its budget slashed by £1 billion next year– all on Hunt’s watch.

Now around 25% of the doctor workforce are non-UK, and 10-15% of all NHS staff.

We are well below the European average in hospital beds per person and doctors per person in the NHS as we are- yet Jeremy Hunt plans to push away up to a quarter of the workforce, cut the training budget to train less doctors who are already doing two or more doctors work, and make no plans to actually address the drop in ‘homegrown’ talent already, a direct repercussion of Hunt’s own morale plummeting war against the profession.
Those are the facts. Unfortunately if you read the Mail comments you will see why Hunt would ignore them; there’s a segment of the populace that laps up this anti-immigrant posturing, even if it’s completely insane as an actual plan.

This is everything wrong with Hunts tenure as Health Secretary- politics before policy before patients. The NHS will only continue to suffer if it goes unchallenged.
Juniordoctorblog.com

2nd January 2017
New year, new diary! Just moved to our forever-family home. Nice area, good primary just round the corner for Charlie and we are only twenty minutes from Dave’s work. Only issue is they just ‘downgraded’ our local A&E– but I’m not worried, although Dave thinks I’m a hypochondriac! GP is local and there’s a big hospital a short drive away. Anyway, back to unpacking!

3rd March 2017
Finally got round to signing us all up at the GP- it’s such a faff. They wanted to see all our passports, and could only sign us up between 1-2pm on Wednesday. Who can manage that? Charlie had a cough for a few weeks so that finally pushed us to join. Waiting time bit long though- two weeks! Oh well. He’s fine.

10th April 2017
Still haven’t got an appointment for the GP! Charlie is looking a bit peaky- it’s been too long now. Phoned up for emergency appointments but the GP never has a free slot. I heard from Linda next door they might have to close- can’t maintain the practice on the funding they’ve got. Never mind. Plenty of other NHS GPs around. Even had a leaflet for a private GP through the door today- £40 an appointment. Bit steep. But booked one anyway. Dave didn’t mind.

17th April 2017
The private GP seemed very nice- referred Charlie for lots of tests though. Dave is worried- he thinks it’s a scam. I don’t. I saw the GPs face- he thinks Charlie is really sick. He asked us if we wanted to stay with the NHS- is that really a thing now? I don’t think we can afford any more private tests. He’s sending us to our local NHS children’s department.

24th May 2017
Waiting for an appointment is agonising. Lost our nerve tonight when Dave thought Charlie coughed up some blood. Everyone was a bit flustered so we went to local children’s A&E- except it was closed. Lack of staff. What the hell does that mean? I’ve never heard of a hospital being ‘closed’. What do we pay our taxes for if not the NHS? We got redirected to another hospital, had a minor divorce-level fight outside the A&E and then decided just to take Charlie home. Our appointment is next week anyway.

1st June 2017
Charlie has cystic fibrosis. I’ve spent hundreds of hours looking all over the Internet and everywhere about it. The specialist at the hospital was very nice- but we were still all in tears. We have another appointment next week. It’s still settling in- my child will always be unwell. I don’t know how to handle this. We tried to see the NHS GP this week- just to touch base. They’ve closed for good. I went back to the private GP for an appointment- looked a lot busier. Had to wait a few days this time. Saw a different GP for £50 this time. Wasn’t very helpful. What a waste of money.

10th Oct 2017
Charlie is managing on his inhalers and things. The NHS department at hospital is great- we have the mobile of Sandra, the nurse specialist for Charlie and any problems just call her up. Heard some mutterings about closing the hospital, ‘centralising’ services. Sounds like a good idea, but Sandra reckons many services like theirs will be cut in the reshuffle. Off the record she said the hospital might close entirely. I left pretty frightened, imagining losing such a lifeline for us. Wrote to my MP when I got back. Why are all the NHS services shutting down?

2nd Dec 2017
Sandra called- they are being moved to another hospital, and their service halved. More ‘efficiency savings‘. She’s not covering anymore- it’ll be a duty nurse system now. I did the maths- our local specialist children’s hospital is now forty miles away. Just shy of 45 minutes by car. What we will do in an emergency? Dave is starting to get chest pains when he’s carrying Charlie up the stairs. We can’t afford to go back to the local private GP right now, the next closest NHS GP isn’t accepting new patients. Just ignoring it now, and hoping.

5th Jan 2018
More leaflets through the door- private health insurance companies offering discounts. Our local NHS hospital has just been taken over by a private firm. Me and Dave had a huge row, and then decided to look into private health insurance. We both believed in the NHS, but it’s clear that it’s not going to survive unless the government step in. Plus Dave is self-employed and so am I- might be a bit trickier. We will struggle through.

20th March 2018
Got insured with Health Co. – few others in the street did the same. Quite steep for me and Dave – lots of cancer stuff on both sides of our family, plus we both run our own businesses. Dave went to an appointment on the very next day- Health Co. GP sent him straight to the heart doctor at the private hospital. Long story short- Dave needs a stent in his heart- not a heart attack, but pretty close according to the doctors. Thank god we got the insurance when we did. Charlie has been good.

1st April 2018
Dave had his heart op today- says he’s feeling much better. Stayed in a nice room in the Health Co. ward- had to pay an excess though, £500. A lot more than we could afford. Really weird feeling as a 1970s child having to worry about money and healthcare in the UK. Anyway- no worries. Everyone’s at home and everyone’s well.

9th April 2018
Health Co. sent us a huge bill today. They say Dave isn’t covered for his op, because he had pre-existing symptoms. Altogether they want nearly £9,000. We were aghast. We tried contacting the NHS hospital to see if they would cover us – we still pay taxes. An hour of ringing got me to a stressed sounding secretary who just laughed in my face. We tried to move back to cardiology at our local NHS hospital- but they don’t do outpatients anymore. Have to raid the savings, probably add a bit to the mortgage too. Need to get the hang of this insurance business better.

15th June 2018
Charlie is sick again – looks like his cystic fibrosis. Went to a great Health Co. GP who wanted to send us to the Health Co. hospital. The hospital wanted to know is Charlie insured. We thought he was- – the hospital says not. An hour of furious tears on the phone turns out they are right- he was excluded because of his cystic fibrosis from a regular family policy. We could pay out of pocket, but the nice Health Co. GP said that might costs hundreds of thousands of pounds. We’d have to sell our house. So I called Sandra- she told us to drive to her NHS hospital, even though it’s an hour and half away. I never expected to be choosing between money or my family’s health. How did this happen? Anyway, we drove to the ‘central’ children’s hospital – and they rushed Charlie to their high-dependency bay. He’s stable now. Dave and I can’t seem to talk to each other, every conversation turns into blaming the other for the insurance rubbish. Bad night for everyone.

17th June 2018
The NHS has really changed- much of the hospital is actually just private companies that have taken over different sections. I’m signing all sorts of documents about insurance and waivers and declining ‘optional’ extras. Whole wards of the NHS buildings are empty. It’s scary. The NHS staff haven’t changed though- Charlie’s paediatric team are the same amazing, hard-working angels they’ve always been. Sandra has been in every day- she looks awful. I’ve never seen her so stressed. I caught her for five minutes to catch up and thank her- I asked her how’s work- and she started crying. Most of her colleagues have left the NHS side, she’s the last cystic fibrosis nurse left in the county for the ‘uninsured’. She gets heartbreaking phone calls like mine every five minutes. She has to turn many of them down. She can’t cope. Every month they get less funding and are told to be more ‘efficient’. She’s close to retirement she told me, so she said she was determined “to see it out”. Her career? I asked. No, she said, “the NHS”.

21st Aug 2018
Charlie is back at home. We did two months driving an hour and a half a day to be with him. We took it in shifts, so Dave and I haven’t really been in the same room for more than twenty minutes for 8 weeks. Our relationship is struggling, but at least Charlie is better. I managed to get him back on a Health Co. policy- but the costs are phenomenal. We had thought about a second baby, and if my business had done better maybe even a third. Now we will settle for Charlie. Health Co. gave us a card to show private ambulances to get to our local hospital. Our GP is private, all of Dave’s cardiology appointments are now private, at huge cost, but at least we are covered.

10th Jan 2019
Dave’s mum had a stroke. She’s 92 and the first we heard about it was a call from a care home telling us she can’t pay. We were shocked. She’d been sent to a ‘central‘ elderly care ward fifty miles away, and then sent back to a care home near Dave’s brother. Obviously Dave’s mum was still on the NHS. Apparently there is supposed to be free coverage for the elderly, but it doesn’t cover care costs. We went to the care home- it seemed nice enough. It’s all private though- the manager was a lovely man, who explained we basically had two options; sell Dave’s mum’s house, the house he grew up in, or move her to the NHS subsidised home a few towns away. We went to the NHS one- bit shocked by how run down it looked. Social care apparently has been cut just as hard as the NHS was– it’s all basically private now unless you can’t afford it. We are selling Dave’s mums house.

3rd May 2019
I found a breast lump today, in the shower. It felt like a hard rubbery knot, just under my right breast. Scared and anxious the first thing I did, still in my towel, was go to the Health Co. policy documents in my office. I read them three times over- trying not to linger on the ‘C’ word, but also making damn sure that if I go to the doctor now, we won’t lose our house. Only when I was sure did I go tell Dave. I felt sick watching his face as he felt it too. We booked into a private GP appointment- have to wait a week now, and still have to pay £60 excess.

30th May 2019
Had all our scans, tests, appointments, re-appointments. It’s a low grade breast cancer. Hasn’t spread- it’s an operation, then chemotherapy for a few years, then done. Sort of relieved, sort of mind-bogglingly terrified. All private staff, all the way through. Dave and Charlie have been very supportive. Hasn’t cost too much in excess payments etc. No holiday this year but let’s get some perspective. Op will be next week.

12th June 2019
Op went well, back at home on tablet chemotherapy. The doctor offered me radiotherapy as well- I thought that was a good idea. Booked in next week.

3rd August 2019
A bill arrived today. Another bill. I can’t cope with this. It’s for some aspects of my cancer treatment- apparently the company made an ‘error’, a lot of treatment was ‘extra-contractual’, bottom line; they won’t pay for it now. The CT scan that gave me the all-clear was ‘extra’, the radiotherapy treatment was ‘extra’, all of the nights in hospital with side effects were ‘extra’. The ‘extra’ cost is £192,000.
I keep looking at that number, wondering how it ever came to this.
My mum had cancer- she had a thyroid lump ten years ago. I went to all her appointments, in and out of NHS hospitals, specialists, scans, surgeons. She’s fine. And she never once paid a penny more than her taxes. What a different world we live in now.

5th November 2019
If I sell my stake in my accounting firm, Dave sells his business and goes back as an employee, and we sell our house and downsize we can just about make the payments without declaring bankruptcy. Charlie’s insurance is gonna hit us hard though.
I saw Sandra in the paper today- I spotted her face protesting in a crowd outside her NHS hospital. Shut down, no funds and not enough staff they say. I text her. She’s retiring now. She’s seen it out, and for her the NHS is over.
For the rest of us as well it seems.

3rd Jan 2020
I did some research. We were all told private companies came to ‘save’ the NHS, that healthcare was no longer ‘affordable’.
But compared to our neighbours the NHS didn’t cost very much- just under 8% of GDP in 2015, well below what Germany and France were spending. We were told that more money was being given to the NHS, but it never really was. Compared with demand the last ever decade of the NHS was also it’s most austere.
Now we can just get by without the NHS- but only just, and we were fairly well off. I worry for those that aren’t. Every day I worry about the next treatment for Charlie or what if my cancer comes back? How will we afford the co-payments and excess charges?
Now the NHS is still around, but it’s gone in all but name. It’s for emergencies and the unemployed and poor only. Basic healthcare. I don’t pay any less tax- more money goes on my family’s hospital bills than ever before.

1st July 2020
A new government is about to be elected. I’m going to campaign hard for the NHS to return. Too many of us are suffering its loss. But no mainstream party has a realistic plan to restore it. It’s simply too late.

It’s been two weeks since the junior doctor body voted no to the proposed contract. The contract designed to “create a seven day NHS”, which we apparently need to address “weekend mortality”. Except none of this is true. And after a year of beating our collective heads against the all, the message is getting through.
In a Parliamentary hearing in February NHS head Charlie Massey admitted he had no clue what a ‘seven day NHS’ meant or was, and no plan to create it. He was told he was ‘flying blind’ on the issue.

But this isn’t news. We’ve been saying it for a year. These are the sticks Jeremy and the department of health have used to beat a whole generation of professionals- the ‘spine’ of the NHS. These are the excuses they have made to replace existing safeguards on working time with flimsy untested alternatives, to discriminate actively against women and parents in medicine, to push morale in the NHS to an all time low.

So what would a rational response be? Your contract has been rejected by the majority, your reasons for creating and pushing the contract have fallen apart, you have a new fresh start in government. You would start over right? Rebuild good will?

Sadly no. Jeremy Hunt is forcing the contract through, and not only that he is now trying to blackmail the group opposing imposition in the courts, Justice 4 Health, by demanding at the last minute £150,000 in costs.

Without this money the court case will never be heard- Jeremy will be free to impose, although he knows this is illegal, and sets a dangerous precedent for every other NHS staff group behind us.

I’m tired, just like you. I just want this to end, just like you. But I also refuse to let our profession and NHS be destroyed. This is our watch. This is our responsibility.

Some of you are doctors, some of you voted No – this is why you voted No. You want a renegotiation, or a moratorium, then imposition must be stopped. It’s time to put your money where your mouth is.

Some doctors voted Yes- you might still want this contract. You might think it’s the best we’re going to get. The yes/no divide was bitter, acrimonious, and brought out the worst in us. A year long dispute as a united profession brought out the best of us. Whether you believe the contract is acceptable or not, we must all agree imposition is wrong. Put your money where your heart is, come together again, and support this cause.

It’s my job as a doctor to interpret trends and analyse hodgepodge information to predict an outcome. I look at the NHS and see a single direction of travel: collapse without rapid and drastic intervention.
In a series of posts we will look at exactly why and how this is happening. This is what I see- you can decide yourself what you see.

In the part 1 here, we looked at why the NHS budget must rise 3-4% per year just to stand still.

In part 2 here we saw exactly how this isn’t happening and the catastrophic effect it’s having on the National Health Service.

Now we examine why.

It’s clear the trend of rising demand and falling budget is not compatible with a sustainable health service, and after six years, the NHS is about to collapse. The question we have to ask is why would our leaders stand by and ignore, even exacerbate, the demise of the one of the safest, most efficient and equitable healthcare systems in the world?

Medicine is all about making choices: when you are faced with two courses of action, how do you decide which to take? What do I think the diagnosis is? What is the probability it is? What is the benefit of treatment? What is the risk if I don’t treat? What is the risk if I do? Standing by and allowing the collapse of the NHS is a choice, not a necessity.

The popular myth about the NHS, and the words certain elements are already chiselling into it’s tombstone, is that it is ‘inefficient’, ‘bloated’, ‘out-dated’, and we simply ‘cannot afford it anymore’.

The entirety of that belief is simply untrue. The NHS is ranked as one of the industrial world’s most efficient healthcare systems, and amongst the sleekest in terms of money spent/individual. Far from ‘out-dated’, NHS researchers and hospitals have pioneered some of the world’s greatest medical advances; Tuberculosis treatments and the first successful kidney transplant*, we invented surgical robots and participated in the world’s first lab grown organ transplant. Most recently we are the first country in the world to vaccinate against Meningitis B.

So the real question is “Can we afford it?”. The short answer is Yes.

The long answer is more complex. Every pound spent on a public system is a choice; it is an ideological choice, a financial choice and a political choice. When the NHS was first created in 1948, the political and financial situation was dire: the UK debt was twice the size of the economy (214% GDP), and politically Nye Bevan faced extreme opposition, including, shamefully, from the professional body of doctors at the time. Here a difficult financial and political choice was trumped by an ideological one; the idea healthcare provision should be available to all. Flash forward to 2008 and the global economic crash required another financial choice; to bail out the banks – at a total potential cost to the UK economy at the time of £1.162 trillion, which meant UK debt doubled from 39% of the economy in 2008 to 84% in 2016.

So the choice to fund the NHS today is actually three choices: political, financial and ideological.

Financially, if we compare 2016 to 1948 – our countries debt is a third of what it was when the NHS was created. Our international counterparts in similar financial circumstances have made a financial choice to spend more of their economy on healthcare. By 2020, that gap will be much more, and we will be spending amongst the lowest in Europe. And remember spending on healthcare isn’t an economic black hole – in areas such as public health every £1 spent to prevent disease saves as much as £5 on future health costs. More on this below.

Politically the NHS remains very well supported. It was even a part of the Olympic opening ceremony. However, the last government made a political choice to stake their reputation as leaders on reducing government spending, for no good financial or economic reason. Many economists and the IMF reject austerity as a means to increase growth in a country.

So what’s the issue?

It’s ideology. George Osbourne and Cameron believed in a small state, and that private competition is the most efficient means to achieve the best allocation of resources, a principle of economics that has no evidence base in healthcare. Despite politically promising no ‘top-down’ reorganisation of the NHS, in 2012 the largest ‘top-down’ reorganisation in the history of the NHS was pushed through in the guise of the Health and Social Care Act. This made it much, much easier for private companies to take publicly funded contracts away from public hospitals. Privatisation of services increased 500% last year.

As public services decline due to lack of public funding, further private companies will come in, and without intervention will eventually take over the entire service. Re-nationalising our hospitals and GP surgeries once this happens will be nigh impossible.

So what can be done?

Well the choice to maintain a publicly funded NHS isn’t as simple as “are we willing to keep spending more money on the NHS?”

There are many areas in the NHS where vast amounts of money could be saved and redistributed, without an extra pound from the Treasury. I’ve written about this before.

The two predominant areas of waste in the NHS are not how care is given, but where care is given. Currently private finance initiative deals provide £11 billion pounds of worth to the NHS, in the form of buildings and maintenance, but will end up costing the taxpayer £80 billion in interest. Hospitals like Barts Health in London pay £2.7 million a WEEK in interest on these deals. Why hasn’t this been addressed? Again it’s a choice not to. An alternative choice would be to nationalise this debt and renegotiate it – even restructuring it to paying 1/3 less would save the NHS £23 billion – enough to fund it fully for the next ten years.

Similarly the cost of administrating competing private companies and contracts in the NHS has a huge cost – estimated at around £5 billion/year. Reverting back to a purely state-funded and public model isn’t an ideological dream of left-wing liberals – it’s a sound money saving effort. Again, it’s a choice not to do this, because ideologically the government has chosen to create a system that prefers private competition, without any good financial, economic or scientific reason.

And if we don’t plan in the long-term to prevent diseases; diabetes, obesity, falls in the elderly, stroke and heart attacks – we are shooting ourselves in the collective foot. But a political choice was made to save short-term money on public health. Cutting social care costs us 2-3x much as it saves: I regularly have patients waiting for relatively cheap social care in highly expensive hospital beds, or contracting easily preventable conditions in inadequate social situations that develop into hugely expensive and life-threatening disease.

This is what happens when an unstoppable force meets an immovable object. Demand for healthcare is currently unstoppable; it rises 3-4%/yr, and without taking preventative measures, will continue to do so. The government is apparently immovable; they steadfastly refuse to meet this demand, which every year creates larger and larger problems as patients suffer in underfunded and understaffed hospitals. Between the two the strain on the NHS has reached critical mass – it will collapse without drastic intervention.

Neither of these forces are truly immutable; we can curb health inflation with proper prevention and better social care, and we can both fund the NHS to an equivalent level for a modern industrialised country, and save vast amounts of money through removing deals that are criminally expensive and wasteful.

I hope you now see the NHS is collapsing, and in dire need of help. This doesn’t have to happen. It is a choice.

Today Jeremy Hunt announced a return to imposition. He justified this despite an emphatic rejection of the contract by 58% of the referendum voters, to end the ‘impasse’ after three years and failing to agree a contract.
But the one question no one has answered for me is “what is the rush?”
Now the government would argue that they are keen to get on with their ‘seven day NHS plans’, despite the fact that the NHS is about to announce even greater spending cuts, George Osbourne has abandoned his surplus target for 2020, and record number of staff gaps for doctors and nurses are being recorded. Categorically, there is no plan for a seven day NHS, vis a vis there is no seven day NHS. What did we get instead? “Junior doctors are now a third cheaper”. There aren’t any more doctors- in fact many have now fled for Australia and Scotland. So no more doctors on weekends- just a third cheaper.
And whatever happened to the ‘weekend effect’- suddenly missing from what was core Hunt go-to doctrine? Well new evidence has dispelled this effect, making it more an artefact of how dodgy data was collected, and subsequently misrepresented. We’ve covered this before. Put simply- there’s no weekend effect for this contract to address.
And even if there were, junior doctors already work 7 days a week, no study ever linked junior doctor staffing to any ‘effect’ and the one study Jeremy likes to quote actually found 100% medical coverage across every day of the week. So this contract fight arose from a political position that has since crumbled away.
So what’s the rush? What’s the benefit of imposing a contract, which is legally fraught, onto a highly mobile professional body, highly
Motivated already to leave?

Now the government might turn back and say- well it’s been three years, and we still haven’t got anywhere.
Be that as it may- but why can’t it be three more years? If this was genuinely all about making patients safer, which it certainly doesn’t now, then why not take the time to actually achieve that?
Let me tell you about the contract. It is going to cover every NHS England hospital- so every patient in England will be affected.
The central Guardian role for protecting doctors from exhaustion, a key concern about this contract, has been rushed through in weeks- but practically no planning has been done.

Some hospitals have recruited this role for a mere 4 hours per week, looking after 1200 doctors. That’s just 12 seconds a week per trainee. Is that sensible or practical?

There is no plan for how human resource departments will be able to cope with the sudden ten-fold increase in complexity in the pay and rostering schedules, nor any plan for how educational supervisors, busy doctors in their own right, are now expected to take on a huge additional workload, another key part of safety completely mismanaged.

We don’t have an effective means of whistleblowing without getting sacked. Put simply- if I find a horrendous breach of patient safety neglected by my hospital management, and blow the whistle to protect patients, I can be sacked from my training post with impunity. Is that a good thing?

Lastly negotiations were still in progress to address the key discriminatory parts of the contract. As it stands it still will mean the careers of female medics are more difficult Than they are now. We are bleeding staff and resources in the NHS- what is the possible benefit of rushing a contract through that will lead to fewer doctors on shift, not more? Is that good for patients or staff or anyone at all?
You might argue that the BMA agreed this contract, and therefore it’s okay to impose it. Which is a rather paradoxical argument from just a few months ago when we were told the BMA were misleading us, now we should blindly follow?
Certain social media commentators ardently claim we are naive and childish. We are a group of people with an average of two university degrees each, twenty plus years of education, an average age of around 33, and many of us mothers and fathers ourselves.

We understand perfectly.
We understand the rush is a political expediency- politically this needs to be out of the news cycle, politically it needs to be off the front page, politically this needs to be out of the next election cycle. But I’m sorry, we aren’t creatures of politics.
We are doctors responsible for human lives; and we see a contract that will push more of our colleagues away from the bedside, stretch the doctors that remain, and leave no means to correct continued unsafe working. I’m not exaggerating when I say this contract imposition may hasten the end of the NHS, and has the very real potential to kill people. It’s not a decision we take lightly or naively. It’s also not a decision or negotiation to rush.

So Mr Hunt, I ask you again: what is the rush?
Work with us for a year to improve the safety mechanisms we have, to retain less than full time staff, to restore the morale and hope of us all. You keep telling us we are the ‘backbone of the NHS’. You are about to break it.
You don’t need a doctor to tell you that’s a rather fatal idea.
#listennotimposition
Juniordoctorblog.com

Why? Well, here’s been a lot of partisan opinions and dog whistling on both sides of the debate- the level of discourse has been a lot like a mud wrestling much- both sides have smeared each other in so much muck that you can’t really tell them apart, and you stop caring.

That isn’t surprising. We have a government right now built on the principle public relations is more important than policy, that what you say and how you appear saying it is far more important than what you do. Sentiment over substance. Both sides of the Tory schism have led the same way, into farce. The whole thing has descended into an Eton schoolyard spat, with Nigel Farage the slightly odd kid no one plays with suddenly joining in, shouting “get him Boris” and other, more racist, things that make everyone uncomfortable.

So I’ve ignored it completely; maybe you have too. Instead I turned to social media, and through my own research made a decision to Remain, based on facts and figures and nothing else.

What’s my conflict of interest? Full disclosure; I am the son of a non-EU immigrant (who is voting Leave FYI), I was state educated and trained and am a junior doctor in the state run NHS. I pay my taxes, vote left of centre, and have a cat from Latvia. As a junior doctor no one despises Cameron, Osbourne and Hunt more for what they are doing to the NHS.

So why on earth would I side with them?

As a doctor I like facts. Cold, hard, rigourous facts. I don’t like subjectivity, vagueness or b******t. I also like human beings. I don’t like discrimination, inequality or suffering.

So here are some myths and some corresponding facts that changed my mind. Maybe they will change yours.

£250 million sounds like a lot/ week- but it works out about £4/person per week, or £16/person per month.

For £16/month we get easy access to a market of 500million people, which means many small businesses in the UK can sell to the EU as easily as to customers at home. This is a very good thing. We send ~45% of our exports to the EU.

Renegotiating all the deals would be possible but: we would have p****d off Europe, we will have pound less strong against the Euro, and we would still have to allow free movement of labour.

3) We could spend that money better on health, like the NHS

This is wrong, but I welcome the support.

The NHS is drowning with Tory underfunding- but it’s the fault of our government, not the EU or immigration.

The economy will recede again if we leave the EU – I don’t really see how it can’t. Economists worldwide agree : but ignore that fact for the moment. A market we export 40% of our goods into, have extensive trade links and agreements from selling into, and have been a part of for 40 years just disappears from our economy overnight. Yes, perhaps we can recover – maybe we can trade more with Brazil, and China, and the US, maybe we can set up the same agreements again with the EU. In the meantime, which will be years, not months, Britain could lose as much as 10% of GDP – that’s around £180 billion, or 1.5 x the budget of the NHS.

During the last period of austerity, worldwide it is estimated 250,000 cancer deaths occurred that otherwise wouldn’t have if the financial crash hadn’t occurred. Let me reiterate that – 1/4 million people DIED, because of financial fraud, in health systems dependent on employment for health insurance. This didn’t happen in the NHS, because of it’s public nature. But if there are further cuts to public spending, further austerity, the NHS will collapse. It might anyway. Money in healthcare means lives- don’t underestimate austerity as merely an exercise in ‘saving pennies’. It saves money from the most vulnerable in our society, and some don’t survive. It’s a crime too big to see.

4) We have to stop immigration and take control of our borders

330,000 people came to this country last year. Half came from the EU, half came from non-EU

We already ‘control our borders’- we have full control over non-EU immigration, and all EU migrants have to present ID and passports to enter the country.

a) Essentially, leaving the EU won’t alter immigration from non-EU, which may increase

b) immigrants contribute more to the economy than they take out: they help us survive periods of austerity and economic downturn, like right now

c) 1.2 million British people live in the EU, and around 3 million European citizens live in the UK. If we deported everyone, and all the Brits returned, our population would fall, but we would have replaced 2 million working people with mostly retirees, who will draw a pension and use extensive healthcare and contribute less to the economy than the working migrants they replaced. Good idea?

5) Other rambling

We have to bail out the Eurozone all the time. No we don’t – we opted out.

The EU is a capitalist wet dream designed to oppress working people. Maybe – but look at the government we have now. (see next point)

We must leave the EU to escape the threat of the Transatlantic Trade and Investment Partnership (TTIP). This clandestine trade agreement between the EU and the US has been negotiated for the past five years in total secrecy – public, press and even politicians involved aren’t allowed to look at any materials. The whole thing was recently leaked – and has many scary and ultra-neoliberal proposals for companies to essentially sue governments on issues that affect it’s profits – like health and safety regulation, or state-provided healthcare. The government recently backed down and exempted the NHS from TTIP – but we haven’t seen the detail yet. To be honest I was planning on voting Leave if I thought we would escape TTIP legislation – but remember who our government is. Cameron basically invented TTIP and would sign up to it ‘in a second’. If we leave Europe we will be left with an even more far-right, ultra capitalistic government, and TTIP would just be imposed under a different name.

I may not have convinced you – but that doesn’t matter. Politics in the digital age is changing, it’s up to us to take the responsibility for how it changes. Will it become a divisive society of online echo chambers, neither listening to each other except to engage in Twitter trolling? Or will we grow up, critically seek out and appraise the facts for ourselves, escape the influence of newspapers trying to sell us sensationalist politicised rubbish, and see the world how it really is.

Remember people literally died for your right to vote. Whatever you do today, go and VOTE.

#voteremain

juniordoctorblog.com

*How? Well, watch The Big Short, but essentially banks were selling mortgages to people who couldn’t afford to repay them, and then selling those debts bundled together to other banks, who then bet on those bundles to never fail, which they obviously, spectacularly did. Imagine your friend set fire to a bit of paper, and said to you “Here, buy this bit of paper, and keep it with your other bits of paper.” Which obviously started a bigger fire, and then you said to another friend “Hey, buy this fire I just started and keep it in your house.” And then someone came along and said to HIS friend : “I bet you £1 billion that house doesn’t burn down.” Sound stupid? This is actually exactly what happened.

In another two part post, juniordoctorblog and guest writer Dr Hugo Farne look into the futures of a ‘Yes’ or ‘No’ vote on the junior doctors contract.

Read Part I- ‘Yes’ here.
We don’t know yet what a ‘No’ vote for members will mean, or even what a referendum result will have to be to be truly accepted as a No by JDC and government. Let’s assume for this psychic exercise that it’s overwhelming.

Here’s what might happen;
– the JDC exec will resign- new representatives will have to come forth and a new negotiation team and strategy formed

– The government may impose the contract

– Justice 4 Health may proceed with a legal challenge to imposition. It’s uncertain if the BMA will proceed with their legal action

Here’s what definitely will happen;

– Everyone will be angry
So what next?

We can model a No vote into five scenarios;

1. Accept an imposed contract

2. Call for a delay while new negotiations and JDC committees are chosen

3. Campaign for a better contract from the May starting point

4. Campaign for a complete withdrawal

5. +\- Campaign for specialised contracts

1. Accept an imposed contract

This obviously is the worst outcome of a No vote. There were significant changes in the ‘imposed’ contract from the terms discussed in February, terms such as the Locum fidelity clause and the ‘we can change anything anytime’ clause. However, there wasn’t a full terms and conditions published at that point which we do have now. How the government would justify republishing terms and conditions without looking as if they are taking advantage would be tricky. It would also give ammo for further protests if the government were to backtrack on what was agreed with the BMA.
2. Call for a delay while a new negotiations committee is chosen

Slim chance of government listening if they think they can impose without a publicity storm. But if they do the BMA can have time to rebuild and reconsider their position and the ongoing strategy, realistically delaying events for six months. A long time in politics and also a cooling off period. Negotiations could start afresh- the govt may have more PR room to manoeuvre, concessions and changes more accepting to junior doctors could happen.

3. Campaign for a better contract from the May starting point

This would be the single most difficult option of all. For the simple reason that justifying increasing protest for what would be small incremental changes from what the BMA accepted would be very difficult. Public support would be stretched, especially given the whatsapp leaks story, which has yet to be definitively addressed by the BMA.
4. Campaign for a complete withdrawal; the ‘leave us alone’ option.

A campaign predicated on this would bullet point to;

– the new contract is less safe and no better than what we have now. (This really comes down to the implementation)

– The toxic contract has damaged morale and retention- the longer it is threatened the worse it will get

– The reasons for original imposition have been since found to be invalid: no link between junior doctors and weekends, no money for seven day services.

– If the new contract is cost neutral then why is it necessary given the above?

– The new contract is still discriminatory against women

But also remember that the public didn’t really get our message the first time. They supported us yes, but the safety message did not register in the polls: most of the public thought it was about pay and conditions. The real question is will they continue to support us?
This argument is particularly hamstrung by the fact that the BMA has accepted and promoted this contract.

The counter message here would be;

– we didn’t accept it- the grassroots said No

– The BMA has to respond to the membership

– It was the best deal from a bad one- but why did it have to be a bad one to start with?5. +\- Campaign for specialised contracts

The difficulty with much of this dispute is in the increasing specialisation of medicine and consequent variability in working practices. What is right for A&E and ITU, providing essentially 24/7 services already, won’t suit GPs or clinic-based specialties (e.g. dermatology), with relatively little overnight work. Maybe it is time to move away from a one-size-fits-all contract, and from a single negotiating team. Let experts from each area design their own working patterns and contracts, within the same cost neutral envelope (Foundation doctors will need a separate deal). Invite BMA representatives with an appropriate background and/or representatives from the relevant Royal College, who set the training curriculum. Empower them to come up with the solution to their own speciality; how to remunerate the different duties of the week that is deemed fair and provide appropriate incentives to encourage retention. At the very least they will have no one else to blame, and in all likelihood they will find a better answer.

So that’s what ‘No’ might look like. If you haven’t read Part 1- ‘Yes‘ yet, go and do so here.

Summary

All of these scenarios will require work and time and support. If you want to vote no, be prepared to fight a very uphill battle. If you vote yes, be prepared to fight to make the contract function as it should in your hospital. This is your 99% perspiration- whatever you choose, it will require your blood, sweat and tears to make it work.